NCS000339_Rescission Request_20201124

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Polhitant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
NOV
Please fill out and return this form if you no longer need to maintain your NPDES stormwater ermit.
UENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N C S (3 -0�p 133 Q N I C I G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name qAMLs1,-- Ll. � r�e e,�� G
Facility Contact jg�f'—Vm &4QJLS1 p4U&
Street Address � ) .4 n1 ii'r—,.rct iz7. _
City State 1\ L%- ZIP Codec "c7 445,
County a vAX.- E-mail Address met
Telephone No. S'^z 7 3 pqq Al Zi
7 r�--
3) Reason for rescission request (7.,. required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on . All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to on . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
N Other:
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4) Certification:
M
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.0A_ )•uq
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. I am familiar with the information contained in this request and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature a��6 Da -'
Print or type name of person signing above Tii�r
Please return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 20183an 10